Managing the revenue cycle for wound care clinics can be overwhelming, and not having a good understanding of the process could result in leaving a lot of money “on the table.” It is important for program directors to realize where revenue opportunities are available, where they may be lost, and how to avoid the pitfalls of not anticipating billing issues before they become denials. (Not to mention the resulting loss of large amounts of revenue.) This has never been more true than with the issues surrounding the use of cellular and/or tissue-based products (CTPs) for skin wounds. Specifically, it can be difficult to understand and frustrating to learn why an account is denied when it appears that everything has been processed correctly. To avoid denials associated with the challenges regarding CTPs, consider implementing a process that closes most problem areas and increases overall reimbursement. This article will offer advice on how to establish such a process.
PRODUCT SELECTION & SIZE
Performing a value analysis of the available products can assist in determining the most cost-effective items. Building a consensus of products to be used with providers and then limiting the number of CTPs and their sheet sizes reduces the potential errors that staff members can make and eliminates the need to add new codes to the chargemaster every time a new product is released to the market. This also allows providers and clinic and billing staff to become more familiar with the products selected instead of needing to remember the properties, dimensions, and requirements of multiple options. Consider selecting products that are more likely to be approved by Medicare and private insurers alike; newer and more obscure products can be denied for being considered “experimental.”
DESIGNATE RESOURCE STAFF MEMBERS
Depending on the size of the wound clinic, it might be helpful to designate one or two staff members who can approve any application of CTPs. This should be a staff member who is familiar with both the clinical and the reimbursement requirements for the product selected. This staff member should also serve as a resource for providers and colleagues and have the authority to grant approval for the procedure prior to it being performed. It is helpful for this resource person to document any approval in the medical or financial record, including the use of a checklist, if necessary, to insure all steps of the process have been properly fulfilled.
KNOW THE MEDICARE LCD
Each clinic should be familiar with the local coverage determination (LCD) for its Medicare jurisdiction. The LCD gives details regarding documentation, appropriate Current Procedural Terminology (CPT®) codes, covered ICD-10-CM codes, and other important and required information for reimbursement. The LCD will outline all requirements for documentation, all of the clinical conditions that must exist before reimbursement can be expected, and how many applications of each product can be performed. Some of the conditional requirements include age of the wound, other conservative measures taken, vascular assessment and status, nicotine assessment and cessation efforts, wound bed preparation, and status of blood sugar control in the presence of diabetes. This is tied very closely to the documentation. If the medical record is documenting that a wound is covered with slough, yet there is no documentation of wound bed preparation with removal of the slough, then, per the LCD, reimbursement should not be expected. At least some Medicare LCDs require wound bed preparation (debridement) to be performed prior to the first application of a CTP. More recently, some Medicare Administrative Contractors (MACs) have been specifically limiting the types of wounds for which CTPs can be used. If the provider places a CTP on a surgical abdominal wound using a product approved only for venous leg ulcers or diabetic foot ulcers, then reimbursement should not be expected.
KNOW EACH INSURER’S MEDICAL POLICY REGARDING CTPS
Each private, major insurer publishes its medical policy and has it available online for anyone to study. Clinic staff members do not need special logins or special privileges to gain access to this information. These policies outline the products that are usually covered for which types of wounds. If a policy states that a particular product is not covered, or is considered “experimental,” then pursuing the case under those conditions usually results in a denial. A good practice is to view these policies before the application of any product each time, as these policies can change at any time.
APPROPRIATE PREAUTHORIZATION & PREDETERMINATION
Contact the patient’s insurance company to verify if the particular CTP and its application are covered on that patient’s plan. Also, verify if preauthorization or predetermination are required before proceeding with treatment. Be prepared to seek approval for both the CPT application and the product’s Healthcare Common Procedure Coding System (HCPCS) code. It is imperative that approval is sought for both. Many times, denials are based on not having an authorization for the product along with the proper application code. Be sure to document any reference numbers or authorization numbers along with the name of the agent(s) who provided the information. Request a fax or email confirmation. If an insurance company is refusing to provide written confirmation or is claiming that preauthorization or predetermination is not required, then proceed with caution. It would be advisable to not perform the procedure and inform the patient of the decision to not proceed based on information provided by the insurance plan.
PATIENT’S FINANCIAL RESPONSIBILITY
Discuss financial responsibility for procedures with all patients and provide them with a written estimate of charges. This provides complete transparency and helps eliminate confusion. Placing a CTP is a costly procedure, and patients may elect to not receive the product because they cannot afford their portion. Other options include to delay the procedure until the deductible has been met or other financial arrangements can be made. Be sure to collect payment up front prior to the procedure. If there is any question regarding insurance or Medicare reimbursement, and the patient is insistent on having the procedure done, be sure to issue a waiver of liability to patients with private payers and an advance beneficiary notice (ABN) of non-coverage to patients with Medicare. This covers the liability of the clinic in the event of a denial, even on appeal, and the patient becomes responsible for the entire balance of the charges. Medicare and other private insurances will not allow a provider to bill the patient directly for denied procedures unless the waiver of liability/ABN is in place prior to the charge being incurred.
Be sure all documentation matches the requirements of the Medicare LCD or the insurance provider’s medical policy and that all aspects have been addressed and pre-procedural conditions have been met. Have clinical staff use a template that contains all the expected elements of documentation. This assists in the standardization of documentation for all providers and will ensure that everything has been addressed in order for reimbursement.
KNOW THE CPT & HCPCS CODES
There are two charges involved with CTPs for outpatient clinics. The first charge is the application of the product (CPT code) on the patient. The second charge is for the actual product or supply (HCPCS code). It is important to know that there are different CPT codes depending on the area of the wound covered, the anatomical location of the wound, and, for Medicare, the high-cost or low-cost designation of the CTP. The provider charges for the application procedure only; however, the clinic charges for both the application procedure and the supply of the product. If you do not charge for both, Medicare will not reimburse for the packaged procedure. Medicare delineates which products are considered low cost and which are high cost. For Medicare, outpatient provider-based clinics (PBDs) should submit CPT codes 15271-15278 for the application of products designated as high-cost and HCPCS codes C5271-C5278 for the application of products designated as low-cost. Some private payers do the same. Some private payers use 15271-15278 for the application of both high-cost and low-cost products.
KNOW THE CORRECT MODIFIERS
The LCD for each MAC jurisdiction will list which modifiers must be used when filing reimbursement claims. The most common modifiers include:
The JC modifier indicates that the product was used as a graft. The JW modifier indicates the amount of the product that was discarded/not administered to any patient. Note that the JW modifier is not used by PBDs. It is, however, required when physicians purchase CTPs and apply them in their offices.
AUDIT ALL DOCUMENTATION
Performing audits at all points along the continuum is essential to avoiding Joint Commission, Medicare, and/or other payer issues. Auditing medical records before and after each CTP application ensures that each staff member has performed the assigned role and that the appropriate reimbursement will be received. Documentation auditing includes tracking the sheets of the CTPs (per Joint Commission requirements), the preauthorization process, the patient’s eligibility to receive the CTP, the procedural documentation, and the coding to ensure that all elements of the payer requirements have been met.
REVIEW ALL DENIALS IMMEDIATELY
If denials have been received, be sure to review and appeal them immediately. Work with denial staff to learn why the claim was denied or what may have been missing on the claim. Appeal immediately, if possible, clarifying the claim. Be sure to review all processes and make changes based on the denial so that the likelihood of another denial is minimized. Denials for CTPs can severely affect clinic profitability. Clinic reimbursement margins are becoming more narrow and money can be saved through process improvement and increased oversight. A few tweaks to the revenue cycle process can allow clinics to provide best practices to patients while increasing healing rates and improving outcomes.
Karen Eilert is clinical manager of the wound care and hyperbaric clinic at UT Southwestern Medical Center – Clements University Hospital, Dallas, TX.